Emerging evidence has consistently shown that flushing central venous catheters (CVCs) with normal saline is comparable to heparin flushes in the adult care setting, leading to updated guideline recommendations that include saline as an alternative. But to date, only two studies have evaluated the two options in pediatric patients, the older of which found increased complications when used in children with leukemia or lymphoma. Is normal saline an acceptable alternative in that population?

In an article in the June 2022 issue of the Clinical Journal of Oncology Nursing, Omatsu et al. reported on the results of their quality improvement project to evaluate the effectiveness of normal saline versus heparin flushes for central venous access devices in pediatric patients with cancer. They also conducted a cost comparison to understand the impact on affordable care and financial toxicity.

Identifying an Opportunity to Improve Practice

Omatsu et al. proposed the use of new institutional flushing guidelines for CVCs in the pediatric patients (aged 6 months–18 years) in their practice. The new guidelines instructed nurses to use a saline lock for all tunneled lines with slight variations based on patient setting:

  • Inpatient: Flush with a push-pause method on a twice-daily (Q12H) schedule to coincide with each shift’s staff line assessment.
  • Outpatient: Flush with a push-pause method when patients are actively receiving care in the unit. If they require daily outpatient infusions and elect to keep their port needle in place, also use a saline lock.

Heparin lock changes are still used for port deaccess and at the time of discharge for all external tunneled catheters, but the dose is reduced from 3 ml (100 units/ml) to 2 ml (10 units/ml) for tunneled catheters and remains the same with 5 ml (100 units/ ml) for port deaccess.

Building the Evidence for Practice Change

From September 2020–February 2021, Omatsu et al. evaluated use of the new guidelines among 62 pediatric patients at their institution. The patients were being treated for a variety of cancers, but the most common diagnoses were B-cell acute lymphoblastic leukemia (ALL) (24%), osteosarcoma (10%), and T-cell ALL (8%). Children’s Oncology Group protocols AALL0932 (11%), AALL1131 (8%), and AOST0331 (8%) were the most common treatment regimens.

The team used a repeated-measures mixed model to compare the differences in alteplase usage rates between pre- and postimplementation groups and conducted a trend analysis. They found a slight increase in alteplase use after implementing the new flushing process, but it was not statistically significant, and they found no trends during the study time period. The cost savings per single lumen, which is a 30-count box of heparin (10 units/ml) 5 ml syringe, was $154 under the new guidelines ($520.20 to $366.24).

The Q12H inpatient flushing cycle exceeded the Infusion Nurses Society guideline recommendation to “flush accessed but non-infusing implanted vascular access ports daily,” Omatsu et al. said, but no central line–associated bloodstream infections were documented during the study period.

Implementing New Processes in Practice

Because moving from flushing with heparin to flushing with normal saline for CVC maintenance was a significant change in clinical practice for the pediatric oncology nurses at Omatsu et al.’s institution, they engaged their nurse colleagues early and communicated the reasons behind the change, including:

  • The evidence for its use and safety in the adult population
  • The cost savings for patients and families

Before the new processes launch date, Omatsu et al. educated all staff, patients, and families with verbal, electronic, and written resources and reinforced the information with patients and families during follow-up visits. They taught providers about the new ordering process and posted flyers as reminders throughout the units.

“This project supports the elimination of a medication that is unnecessary for CVC line maintenance and provides evidence indicating the safety and effectiveness of using normal saline to flush CVCs in pediatric patients,” Omatsu et al. concluded. “The evidence drawn from this project indicates the ability to maintain central line patency without the use of additional medications, thereby reducing monetary expenses and directly affecting the clinical care of patients with cancer.”